5–7 minutes · No payment collected · Reviewed by MyFlowMD clinical team
Please complete this form before your consultation. This allows our physician team to review your history and personalize your care plan.
Your intake is reviewed by the MyFlowMD clinical team.
No payment is collected here.
If care appears appropriate, we follow up with next steps for physician-guided treatment options.
Your consultation is free. Peptide and GLP-1 programs have no membership or startup fees.
Testosterone care uses a 6-month membership model that includes the services listed on the website; if TRT is appropriate, our team will review that pricing model before you order.
Full Legal Name *
Date of Birth *
Sex * MaleFemale
Phone Number *
Email Address *
Street *
City *
State *
ZIP *
Medical weight lossHormone optimizationPeptide therapyLongevity / preventionEnergy & performanceMuscle gainSexual health
Other (please specify)
Height (e.g., 5'10" or 178cm) *
Weight (lbs) *
Have you ever been diagnosed with any of the following?
High blood pressureHigh cholesterolHeart diseaseStroke / TIAThyroid disorderAutoimmune diseaseCancerKidney diseaseLiver diseaseSleep apneaDepression / AnxietyADHDOsteoporosisChronic painNone
Other medical conditions
Surgical history (list procedures)
Hospitalized in the past 2 years? * NoYes
If yes, please explain
Please list all prescription medications (include dose if known)
Please list all supplements or peptides you are currently taking
No known drug allergies
Medication allergies
Food allergies
Do you or a family member have a history of:
Medullary thyroid carcinomaMEN2 (Multiple Endocrine Neoplasia Type 2)None
Exercise frequency * None1-2x/week3-4x/week5+ times/week
Nutrition style * StandardMediterraneanPaleoKetoVegetarianHigh proteinOther
Alcohol use * None1-3 drinks/week4-7 drinks/week7+ drinks/week
Tobacco / nicotine * NeverFormerCurrent
Sleep per night (hours) *
Stress level (1-10) *
When were your most recent labs completed? (Month / Year)
Regular cyclesIrregular cyclesPregnant or trying to conceive
Prior low testosterone diagnosisPrior TRT useFertility concerns
I confirm that the information provided is accurate.
I understand that medical eligibility will be determined by a licensed physician.
I consent to communication via phone, email, or text regarding my care.
Electronic Signature (Type your full name) *